Date of Near Miss
Name of Person Completing Form (Last, First, Middle Initial)
Contact Phone Number:
Witness Name (Last, First, Middle Initial)
Witness Phone Number:
Location of Near Miss
Near Miss Description: Describe procedure being followed, including equipment which was related to the near miss.
Corrective Actions: What should be done or has been done to prevent recurrence of this incident? Ex: employee training, change of procedures, purchasing of equipment, etc.
Miscellaneous Information (Provide any other information or recommendations which you feel are pertinent to the incident)
Email any supporting photos or documents if necessary to: firstname.lastname@example.org
Connelly & Associates
1513 Tilco Drive
Frederick, MD 21704